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Research Article | DOI: https://doi.org/10.31579/2640-1045/151
North Manchester General Hospital, Department of Urology, Delaunays Road, Crumpsall, Manchester. United Kingdom.
*Corresponding Author: Anthony Kodzo-Grey Venyo, North Manchester General Hospital, Department of Urology, Delaunays Road, Crumpsall, Manchester. United Kingdom.
Citation: Anthony Kodzo-Grey Venyo, (2023), Ectopic Thyroid in The Ovary, Uterus and The Pelvis: A Review and Update, J. Endocrinology and Disorders, 7(7): DOI:10.31579/2640-1045/151
Copyright: © 2023, Gambhir, Kanwal K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 19 July 2023 | Accepted: 10 August 2023 | Published: 21 September 2023
Keywords: ectopic thyroid; ovary, uterus, abdominal pain; loin pain; bleeding; euthyroid; thyrotoxicosis; ultrasound scan; computed tomography scan; magnetic resonance imaging scan
Ectopic prostate in the ovary, the uterus or within the female genital tract is a rare entity which majority of clinicians globally would not have encountered during their training as well as globally and may therefore not be familiar with the manifestations, diagnostic features and management of this rare clinical entity. Struma ovarii is a terminology that is used for a specialized or mono-dermal teratoma which predominantly is comprised of mature thyroid tissue. With regard to struma ovarii, it has been iterated that the thyroid tissue must comprise of more than 50 percent of the overall tissue I order to be classified as a struma ovarii. It has been stated that Struma ovarii does account for about5 percent of all ovarian teratomas. It has been iterated that depending upon the histology features, struma ovarii can be classified as either (a) benign or (b) malignant. Females who have struma ovarii have been documented to usually manifest with abdominal pain and/or a pelvic mass and less frequently with ascites. Ladies with ectopic thyroid tissue within the ovary or uterus may also be asymptomatic and they may be diagnosed incidentally based upon the investigation and treatment of a different clinical entity. A lady who has Struma ovari and a large pelvis mass that is compressing a ureter may also manifest with loin pain due to compression of the ureter that may simulate ureteric colic or with constant loin pain for which or rare occasions may be referred to a Urologist. A female with Struma ovarii or ectopic thyroid in the uterus may also manifest with vaginal bleeding. Depending the age of the female who has ectopic thyroid tissue in the ovary or uterus, she may initially be seen by her General Practitioner and referred to a paediatrician, a gynaecologist, a General Surgeon or Urologist depending upon the site and nature of her pain. The clinical and biochemical features of hyperthyroidism tend to be not common in women who have struma ovarii, which has been stated to occur in less than 5 percent to 8 percent of cases of struma ovarii. The clinical presentations of struma ovarii have tended to be based upon single case reports and small case series The ensuing summations had been made regarding Stuma ovarii:
Laboratory Studies that to be undertaken in patients who have ectopic thyroid in the ovary, uterus and genital tract include: Full blood count, routine biochemistry blood tests, blood type and screen, cancer antigen 125 (CA125), CA125 is a non-specific marker which is elevated in various benign clinical settings, including: menstruation, pregnancy, endometriosis. CA125 is raised in epithelial ovarian, endometrial, bowel, breast, and lung cancer. CA!25 was stated to be raised in only 8 cases reported in the literature in the setting of struma ovarii. Thyroid function tests need to be ordered only in patients who have symptomatic hyperthyroidism)
CT and MRI appearance of these tumours might demonstrate helpful diagnostic features. Triple-contrast CT scan of the abdomen and pelvis should be undertaken to evaluate the extent of disease and the involvement of lymph nodes and other adjacent structures (for example, bowel). Typically, struma ovarii does appear as a multi-cystic mass with no or moderate cystic wall enhancement. Ultrasound scan of the pelvis abdomen and trans-vaginal ultrasound could be undertaken as an optional radiology imaging if a CT scan has already been undertaken. With regard to patients who have pelvic masses of unknown origin, mammography should be undertaken.
For the vast majority of cases, surgical resection of the ovary has been stated to be sufficient to treat benign, unilateral disease. A paucity of evidence does exist in the literature regarding conservative management in cases with evidence of malignancy. In these patients, serum thyroglobulin levels could be followed as a marker for assessment for recurrence following fertility-sparing unilateral salpingo-oophorectomy. With regard to individuals who do not desire future fertility, it has been iterated that malignant struma ovarii necessitates the undertaking of surgical staging for ovarian cancer with pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node sampling, total thyroidectomy, and radioactive I-131 ablation. The recurrence rate in patients who have malignant struma ovarii who undergo surgery without subsequent radio-ablation had been documented to be as high as 50%. Some of the differential Diagnoses of ectopic thyroid in the ovary (Struma ovarii) include: (a) All other forms of ovarian neoplasms, both benign and malignant, (b) Ectopic Pregnancy, (a) Endometrioma; (d) Hydrosalpinx, (e) Hyperthyroidism and thyrotoxicosis, (f) Metastatic thyroid cancer to the ovary, (g) Physiological ovarian cyst, and Tubo-ovarian abscess. With regard to patients who have a benign struma ovarii, standard surgical follow-up is sufficient. With regard to patients who have malignant disease on surgical pathology, postoperative adjuvant therapy with radio-ablative iodine-131 has been recommended. After surgical staging, a thyroidectomy has been suggested to be undertaken before adjuvant therapy to potentiate the effects of radio-ablation. As normal thyroid cells preferentially uptake I-131, thyroidectomy would ensure delivery to the malignant cells. Additionally, it has been iterated that a thyroidectomy would provide pathological confirmation that the struma is indeed ovarian in origin. It has been pointed out that it is important for the surgeon to be aware of the intra- and post-operative complications of thyroidectomy which include hypocalcaemia, damage to the recurrent laryngeal nerve, and/or need for postoperative thyroid replacement, as well as to be comfortable with their management. Radioactive I-131 ablation had been reported to treat malignant disease in both its initial presentation and any subsequent recurrence with excellent efficacy, even though the rarity of the disease and lack of data surrounding its long-term management do prove challenging to clinicians. Thyroglobulin is stated by some authors to be the preferred tumour marker followed in patients with malignant struma ovarii and should be followed sequentially after surgery and ablation. It has also been advised that increases in serum thyroglobulin should be followed up with total body scanning in order to identify recurrence, which is treated with subsequent radio-ablation.
The finding of thyroid tissue outside the thyroid gland could occur in various clinical settings and anatomical locations and these include both benign as well as malignant differential diagnoses. [1] Some of these entities of the finding of thyroid tissue outside the confines of the thyroid gland include thyroglossal duct cyst, lingual thyroid, parasitic nodule, thyroid tissue within a lymph node, ectopic thyroid in the ovary. struma ovarii. With regard to the setting of routine daily clinical practice, these ectopic positions of the thyroid gland do tend to pose diagnostic challenges for the clinician and the pathologist. Differential diagnostic considerations do largely depend upon the location of lesion and the histology features of the ectopic thyroid tissue. A definitive diagnosis may remain not be clear in some cases of ectopic thyroid tissue while knowledge is still evolving in others for example, incidentally identified bland looking thyroid follicles within a lateral lymph node. Many patients who have ectopic thyroid in the ovary would be asymptomatic and the diagnosis would tend to be established incidentally during investigation of a non-related problem Nevertheless a number of individuals with ectopic thyroid in the ovary would manifest with non-specific symptoms and unless the clinician has a high index of suspicion for ectopic thyroid in the ovary, the diagnosis may be either delayed or missed. Large ectopic thyroid tissue within the ovary could obstruct the ureter and apart from manifesting as lower abdominal pain in all age groups that would require the patients initially being seen by General duty practitioners, pediatricians, emergency clinicians, or General Surgeons, manifestation of loin pain or impaired renal function may require that the patient is first seen by a Urologist for further assessment. The ensuing article on ectopic thyroid tissue in the ovary is divided into two parts: (A) Overview which has discussed General aspects of ectopic thyroid tissue and (B) Miscellaneous Narrations and Discussions from Some Case Reports, Case Series and Studies Related to Ectopic thyroid in the ovary.
To review and update the literature on ectopic thyroid in the ovary, uterus and the female genital tract.
Various internet data bases were searched including: Google, Google Scholar, Yahoo, and PUBMED. The search words that were used included: Ectopic thyroid in ovary; Ovarian ectopic thyroid; Struma Ovarii; Ectopic thyroid tissue in the ovary, benign thyroid tissue in the ovary, and malignant thyroid tissue in the ovary, ectopic thyroid in the uterus; uterine thyroid. Forty-two (42) references were identified which were used to write the article on ectopic thyroid in the ovary that has been divided into two parts: (A) Overview which has discussed General aspects of ectopic thyroid tissue and (B) Miscellaneous Narrations and Discussions from Some Case Reports, Case Series and Studies Related to Ectopic thyroid in the ovary.
[A] Overview
Definition / general
Essential features
Epidemiology
Sites
Pathophysiology / aetiology
Clinical features
Diagnosis
Laboratory Tests
Urine Examination
Haematology Blood Tests
Biochemistry Blood Tests
Radiology description
Prognostic factors
Treatment
The treatment options that tend to be utilized for the management of ectopic thyroid in the ovary had been summarized as follows: [2].
Gross description
Frozen section description
Microscopy histopathology description
The microscopy pathology examination features of ectopic thyroid tissue within the ovary had been summarized as follows: [2].
Cytology description
It has been iterated that cytology examination of specimens of ectopic thyroid in the ovary does demonstrate the following: [2].
Immunohistochemistry Staining
Positive stains
It has been documented that specimens of ectopic thyroid tissue in the ovary do exhibit positive immunohistochemistry staining for: [2].
Negative stains
It has been documented that specimens of ectopic thyroid tissue in the ovary do exhibit negative immunohistochemistry staining for: [2].
Molecular / cytogenetics description
The molecular / cytogenetics description of ectopic thyroid of ovary specimens had been iterated to demonstrate the following: [2].
Differential diagnosis
The differential diagnoses of ectopic thyroid in the ovary had been summarized to include the following: [2].
[B] miscellaneous narrations and discussions from some case reports, case series, and studies related to ectopic thyroid in the ovary.
Iranparvar Alamdari et al [18]. stated the following:
Iranparvar Alamdari et al [18]. reported a 10-year-old girl who had manifested with tachycardia, normal thyroid examination and thyrotoxicosis. She had thyroid scan which demonstrated no uptake with increased uptake within her right ovary which was indicative of struma ovarii. She underwent oophorectomy and thyroidectomy, Pathology examination of the excised specimens showed papillary thyroid carcinoma limited to the struma ovarii. Following TSH suppressive therapy and treatment with I131, she was totally symptom free at the time of publication of her case [18]. iterated that Struma ovarii should be a possible diagnosis in any female patient who has thyrotoxicosis manifestations with normal thyroid scan and examination. Detailed summation of the case report and educative summative discussions of Iranparvar Alamdari et al [18]. have been detailed out as follows:
Iranparvar Alamdari et al [18]. reported a 10-year-old girl who had presented with the complaint of palpitation to a cardiologist. She was found to have a normal clinical examination and laboratory tests, except for the fact that she had tachycardia with a heart rate of 130 per beats per minute, and low TSH levels (0.005) with normal T3 (9.46) and T4 [145]. She was referred to endocrinologist for possible evaluation for hyperthyroidism. Her thyroid gland was normal with regard to size, with no nodularity. She was diagnosed as having a possible thyrotoxicosis, but due to her normal physical examination finding, she underwent thyroid scan to exclude a possible thyroiditis, which did not show any uptake within the thyroid gland, while there was an increased uptake within her right ovary (see figure 1). She underwent pelvic trans-abdominal ultrasound scan which showed a heterogeneous complex solid mass that measured 113 mm × 112 mm × 100 mm with a volume of 670 cc in her right ovary with no ascites. She did not have any complaint of abdominal pain or pelvic pain or abnormal uterine bleeding.
Figure 1: Reproduced from [18] Under Creative Commons Attribution License.
Thyroid scan showing no uptake in the thyroid gland, but increased uptake in the right ovary.
She was treated with methimazole 10 mg daily and propranolol 40 mg daily and she was considered to be a candidate for surgery after being euthyroid. She was referred to a gynaecologist with the possible diagnosis of struma ovarii for further evaluation. She underwent right oophorectomy with the presumption of teratoma combined with thyroid-stimulating hormone (TSH)-suppressive therapy following treatment with I131. Total thyroidectomy was undertaken in order to permit evaluation for metastatic disease and monitoring for recurrence by thyroglobulin levels. The pathology examination findings of the excised ovarian mass were reported to have indicated teratocarcinoma with 60% well-differentiated follicular thyroid carcinoma and 40% well differentiated follicular-variant with tumour necrosis, microscopic capsular invasion and peri-tumoral lympho-vascular invasion, which was considered to be a tumour stage IC of PTC (see figure 2) and the thyroid gland did not show pathology features of PTC.
Figure 2: Reproduced from [18]. Under Creative Commons Attribution License.
Mature teratoma adjacent to tumour.
She underwent further evaluation with whole body scan with Iodine 123 [I123]. and the scan showed metastasis to lymph nodes. She had high levels of thyroglobulin and she received iodine therapy (150 mCi) twice. During her follow-up assessment, she had a follow-up whole body scan, which had demonstrated no trace of iodine uptake and the patient was symptom free. At the time of the report of her case, she was reported to be under treatment with levothyroxine 0.1 mg daily. Following 8 months after she had undergone surgery and iodine therapy, she was reported to be totally symptom free. Iranparvar Alamdari et al. [18] made the ensuing summating discussions:
Wu et al. [27] reported a 48-year-old female who was admitted to their clinic due to haematochezia with a past history of left malignant struma ovarii. She had undergone an Enhanced computed tomography (CT) examination which had suggested multiple metastasis nodules within her abdomen and pelvic cavity. She underwent laparoscopy and laparoscopy biopsy results of intraperitoneal nodules showed a metastasis of papillary thyroid carcinoma. While pathological examination after total thyroidectomy did show no definite malignant tumour component within the thyroid tissue. Finally, combined with the patient's past history of malignant struma ovarii, peritoneal implantation metastasis derived from the malignant struma ovarii was adjudged to be the diagnosis. The patient was treated by the undertaking of total thyroidectomy and iodine 131 (I) therapy. Her post-therapy iodine scan and her single-photon emission computed tomography/computed tomography (SPECT/CT) fusion image showed iodine uptake within her distal descending colon, sigmoid colon, rectal lesions, and a larger lesion in the liver. Wu et al. [27] reported that after treatment, although the thyroid globulin had remained at a high level 3 months after her treatment, the patient's haematochezia was relieved. Wu et al [27]. iterated that thyroidectomy followed by adjuvant I treatment should be recommended in patients who have malignant struma ovarii as metastatic risk is difficult to predict based on histopathologic examination. Wu et al. [] made the ensuing conclusions:
Jin et al. [28] stated the following:
Jin et al [28]. reported a case of benign struma ovarii, manifesting with the clinical features of advanced ovarian carcinoma: complex pelvic mass, gross ascites, bilateral pleural effusion and markedly elevated serum CA 125 levels. The patient did total abdominal hysterectomy and bilateral salpingo-oophorectomy. Ascites and pleural effusion were not evident and the CA 125 levels had returned to normal level following surgical excision. They performed a systematic review of reported cases of coexistent benign struma ovarii, pseudo-Meigs' syndrome and elevated serum CA 125. They iterated that Struma ovarii accompanied by pseudo-Meigs' syndrome and elevated serum CA 125 should be considered in the differential diagnosis of ovarian epithelial cancer.
Gomes-lima et al. [29]. reported the case of a patient who had two independent papillary thyroid carcinomas (PTCs) in struma ovarii and the thyroid gland that were driven by different RAS mutations. Gomes-lima et al. [29]. reported a 62-year-old woman who had a history of chronic lymphocytic leukaemia/small lymphocytic lymphoma which was diagnosed with a pelvic mass during a CT scan. She had undergone surgery which included removal of her ovaries. A 7.2-cm classical variant of PTC arising in a struma ovarii was identified within her right ovary. Two months after the pelvic surgery, total thyroidectomy was undertaken, and a small nodule (0.8 cm) in the left lobe was found which was diagnosed as a classical variant of PTC. Molecular analysis of tissues obtained from both the malignant struma ovarii and thyroid gland was undertaken. RAS mutations both in the PTC located within the thyroid and ovarian tissues were identified. Nevertheless, the thyroid gland tumour showed an HRAS Q61R mutation, the PTC in struma ovarii harboured an NRAS Q61R mutation. Gomes-lima et al. [29]. stated that in this case, the finding of distinct types of RAS point mutation in thyroid cancers at two different locations had provided definitive evidence that these cancers are synchronously developed independent primary tumours. Gomes-lima et al. [29]. made the ensuing conclusions:
Sah et al. [30]. stated the following:
Sah et al. [30] reported an ovarian neoplasm with components of Brenner tumour, mucinous cystadenoma and struma ovarii. Sah et al. [30]. stated that as they were aware, this combination had not been previously reported. Sah et al. [30]. speculated on the possible histogenesis of this combination of elements.
Wei at al. [5] stated the following:
Wei et al. [5]. reported that a total of 118 patients who had mature teratoma containing thyroid tissue were identified within their institution between 1989 and 2014. Ninety-six cases were diagnosed struma ovarii, including 10 cases of papillary thyroid carcinoma, 1 case of highly differentiated follicular carcinoma of ovarian origin (HDFCO), 5 cases of strumal carcinoid, and 80 cases of struma ovarii (53 cases of thyroid-only struma ovarii). Six of the cases had diffuse adenomatous hyperplasia, and seven cases had focal adenomatous hyperplasia. There was no recurrence upon follow-up except one of the papillary thyroid carcinomas. Concurrent primary ovarian lesions that were found included: serous cystadenoma--3, mucinous cystadenoma--4, Brenner tumour--3, thecoma--2, ovarian fibroma--1, and focal hilus cell hyperplasia--4 cases. Wei et al. [5]. iterated that in their case series, papillary thyroid carcinoma and strumal carcinoid were the most common well-differentiated neoplasm/malignancies arising in struma ovarii; these had demonstrated a minimal or no aggressive clinical behaviour.
Salibay et al. [31]. stated the following:
Salibay et al. [31]. reported a unique case of a 53-year-old woman who had a unilateral ovarian borderline Brenner tumour that was associated with focal atypical mucinous epithelial proliferation and her clinical presentations. Salibay et al. [31]. documented the clinicopathological features of the tumour and the literature review along with the clinical molecular advances were summarized in this study.
Xiao et al. [32]. stated the following
Xiao et al. [32]. reported a 55-year-old female patient who had presented with a history of pain within her right hepatic region for approximately 1 year. She had computed tomography scan and magnetic resonance imaging scan which showed a solid cystic mass within her right adnexal region and a solid mass with her the right retroperitoneum. She underwent surgical resection, and the combined morphology and immunohistochemical results led to the final diagnosis of right struma ovarii with papillary carcinoma and right retroperitoneal lymph node metastasis. Xiao et al. [32]. made the following conclusions:
Terada et al. [33] stated that ovarian tumour which is composed only of Brenner tumour and struma ovarii is very rare and by the time of publication of their case; only 6 cases had been reported in the English literature, to the best of their knowledge. Terada et al. [33]. reported a 66-year-old woman underwent who had undergone right oophorectomy because of torsion of her right ovarian cyst. Macroscopically, the ovarian cyst was noted to be haemorrhagic and red. Cystic content was haemorrhagic fluid. Microscopy examination of the specimen demonstrated that the cyst walls were composed only of Brenner tumour (50% in area) and struma ovarii (50% in area). Haemorrhage and ischemic changes were also seen upon the microscopy examination. Other elements were not recognized. No malignant transformation was found. These two elements were separately present, and no mergers between them were recognized. Immunohistochemistry staining studies had demonstrated that the Brenner tumour element was positive for cytokeratins (AE1/3 and CAM5.2) and Ki67 (labelling=3%), but negative for thyroglobulin, TTF-1, p53, CA125, and vimentin. The struma ovarii element was positive for cytokeratins (AE1/3 and CAM5.2), thyroglobulin, TTF-1 and Ki67 (labelling=5%), but negative for p53, CA125 and vimentin. The findings were documented to have suggested that there were cases of ovarian cyst composed only of Brenner tumour and struma ovarii, that such a case may be mono-dermal mature cystic teratoma or the Brenner tumour element had been derived from surface epithelium in the preexisting struma ovarii, and that such a tumour had manifested as cystic torsion.
Yilmaz et al. [4] stated the following:
Yilmaz et al. [4]. reported a case of an ectopic thyroid within the uterus without evidence of a primary thyroid gland tumour. Yilmaz et al. [4]. iterated that to their knowledge, their reported case was the first report of an ectopic thyroid within the uterus. Yilmaz et al. [4]. reported a 45-year-old woman who was admitted to the Gynaecology Department of the Dicle University Medical Faculty for a hysterectomy after the incidental finding of multiple uterine leiomyomas. The patient's thyroid gland was slightly enlarged upon palpation due to multinodular goitre. The patient had had fine-needle aspiration biopsy for diagnosis but the result of the aspiration was reported as benign. Macroscopy examination of the hysterectomy specimen showed a deformed uterus due to numerous intramural and subserous leiomyomas; the endometrial mucosa was found to be moderately atrophic and the cervix was affected by erosion–re-epithelialization processes (Naboth cysts). The adnexa appeared normal. A sample was taken from a nodular, colloid–haemorrhagic-looking area of 8 mm in diameter in the basal lumina of the endometrium. Histopathology examination of this area had demonstrated a circumscribed lesion with follicles containing some colloid substance. The follicles on pathology were found to be uniform and lined with a monolayered cuboidal epithelium, with neither nuclear atypia nor hyperchromatism; no psammoma bodies or papillary structures were found. This thyroid tissue separated the surrounding tissue without infiltrating it. Immunohistochemistry staining studies by the peroxidase–anti-peroxidase (PAP) method was undertaken on formalin-fixed, paraffin-embedded sections, utilizing rabbit antiserum against human thyroglobulin (Dako, Carpinteria, CA, USA). Epithelial cells and colloid substance in the follicles were noted to have exhibited positive staining for thyroglobulin. The diagnosis was made of ectopic thyroid tissue in the uterus. Yilmaz et al. [4]. made the ensuing summating discussions:
Frysak et al [42]. stated the following:
Frysak et al. [42]. reported a patient who had a history of Graves' disease who had undergone thyroidectomy combined with postoperative 131I radioablation. Despite the previous treatment which she had undergone, she developed an outburst of hyperthyroidism ten years later. Only very close follow-up enabled Frysak et al. [42]. to disclose the right condition. The ovarian source of thyroid hormone production was removed by laparoscopic adnexectomy and a right sided benign ovarian struma was confirmed. Frysak et al. [42]. concluded that most patients who are treated by thyroidectomy and radioiodine do not require extended periods of follow-up or postoperative investigations, but when the clinical or laboratory signs change, clinicians should be prepared to perform the necessary re-evaluation in order to provide the best care.
None
Acknowledgements to:
International Journal of Surgical Case Reports (Int J. Surg. Case Rep) and Elsevier Ltd on behalf of IJS Publishing Group Ltd., for granting permission for reproduction of figures and contents of their journal article under Creative Commons agreement under Copy Right © 2018 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
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Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
